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The Healing Power of ECT

by Joshua Bess, M.D.

There are myriad words used by patients and providers when discussing electroconvulsive therapy (ECT): “complicated,”
“effective,” “drastic,” “antiquated,” “hopeful,” “lifesaving,” and
“scary” are just a few. As someone who has studied and practiced
ECT for many years, I can attest that there is at least some truth
to all of them. ECT has been around for a very long time – much
longer than antidepressants, mood stabilizers, and antipsychotics.
These medications and several other “brain stimulation”
modalities have been developed and refined since ECT was
invented. But for an important subset of patients – especially the
most severely ill – ECT remains the most effective treatment
option available.

For centuries, physicians had wondered about a link between
seizures and improvement in the condition of patients suffering
from what was then called “lunacy.” Chemically-induced
convulsions were administered to patients in the latter 19th and
early 20th centuries, but the agents used were quite unpleasant.
Scientists in Switzerland worked out how to induce seizures in
animals using electrical current, and Italian scientists Cerletti and
Bini translated that research to the first human patient in 1938.
A young man who was found delusional in a train station received
11 treatments and made a full recovery.

In the 1940s ECT took its place alongside several other “somatic”
(i.e. physical, as opposed to psychological) treatments employed
by psychiatrists. Through the 1950s and 1960s the first effective
medications for psychiatric illness were developed. By the late
1960s and into the 1970s, ECT use was declining, in part due to
increase in stigma and negative media portrayals, despite the fact
that through that same period modern anesthesia techniques
and other advances markedly reduced patient discomfort and
increased safety of the procedure. Through the 1980s, recognition
of the limited efficacy of medication in some patients as well
as a general increase in acceptance of the need to treat mental
illness allowed ECT to make a comeback of sorts, again taking a
place amongst legitimate, effective treatments for patients who
otherwise would suffer severely.

ECT is performed either in the pre-operative/post-anesthesia
(PACU) area of the hospital or in a separate ECT suite. The
patient is under the care of an anesthesiologist or nurse
anesthetist and an attending psychiatrist throughout the entire
procedure. Monitors are attached to the patient to assess vital
signs and brain function (EEG) during the procedure. Intravenous
sedative is administered at a dose that causes the patient to be
completely asleep. A muscle relaxant is then administered to
prevent the patient from having physical convulsions during the
seizure. Once everything is ready, a small electrical current is run
through one part of the patient’s brain to another, depending
on the specific type of ECT being performed. This current – the
“stimulus” – results in a generalized, whole brain seizure. The
seizure is monitored via the EEG and usually lasts between
30 and 60 seconds. The whole procedure from administration of
anesthetic until the patient begins to awaken takes about
5 minutes.

The most common indication for ECT is “treatment-resistant
depression.” Such an episode can be part of bipolar disorder or
major depressive disorder. Usually ECT is only recommended
after a patient has tried several, even many, medications – hence
the term “treatment-resistant.” However, there are situations in
which ECT is recommended as a first-line treatment. These are
cases in which either medications are potentially more dangerous
than ECT (pregnant or elderly patients) or when the symptoms
are so severe that the quickest response possible is desired
(extreme malnutrition or strong suicidal urges). ECT can also
be helpful in patients suffering from the manic phase of bipolar disorder or an acute psychotic episode in schizophrenia.

Against the forces of stigma, less drastic treatment interventions,
and regulatory obstacles, ECT continues to offer hope for
thousands of patients suffering from mood disorders and their
disabling symptoms. The safety and tolerability of the treatment
have improved markedly over the years. I hope that the availability
of this important treatment modality continues to improve and
that more individuals will be able to gain relief from lives of
intense suffering. While I also hope for further advances in other
therapies, and eventually for treatments that are as effective as
ECT without the complexity and historical “baggage,” for now
I will continue to encourage my patients and their families to
proceed with
ECT in cases
where all else
has failed or
where ECT is
the safest or
most effective
treatment
regardless of
alternatives.